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Coverage determination

Updated on December 15, 2021

During the claim adjudication process, claims are evaluated to determine whether the services provided to the member have been delivered according to the member’s plan evidence of coverage.

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There are three processes that support the coverage determination capability.

  • Benefit match is the process by which claims information is matched with product and benefit information to confirm whether the services delivered are covered under the terms of the member’s defined health benefits and apply all the corresponding benefit adjudication rules.
  • Benefit limits is the process to ensure that the claim does not exceed any limits that have been configured as part of the benefit. Adjustments to the claim are made when the limits are exceeded.
  • Authorization match / application is the process to match the claim to an authorization for a pre-authorized service based on the benefit configuration detailing that an authorization is required. In the instance the authorization is required and is matched, the authorization will be applied to the claim for adjudication.

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